“Practical Strategies in Medication Adherence in Patients with Cardiovascular Disease” MOTIVATIONAL INTERVIEWING: What is it? Does it work? Julie Culligan,

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Presentation on theme: "“Practical Strategies in Medication Adherence in Patients with Cardiovascular Disease” MOTIVATIONAL INTERVIEWING: What is it? Does it work? Julie Culligan,"— Presentation transcript:

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2 MI Philosophy "People are generally better persuaded by the reasons which they have themselves discovered than by those which have come in to the mind of others.” "People are generally better persuaded by the reasons which they have themselves discovered than by those which have come in to the mind of others.” ~ Blaise Pascal, French mathematician, physicist and religious philosopher

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Learning Objectives Specify and discuss 3 elements of the “spirit” of Motivational Interviewing Specify and discuss 3 elements of the “spirit” of Motivational Interviewing Identify the 4 principles of Motivational Interviewing Identify the 4 principles of Motivational Interviewing Identify basic use of the following core MI skills: open-ended inquiry, affirmation, reflective listening and summaries Identify basic use of the following core MI skills: open-ended inquiry, affirmation, reflective listening and summaries

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4 Facilitating Behavior Change What makes behavior change so hard? It works for us It works for us “Habit” “Habit” It often involves multiple behaviors It often involves multiple behaviors Knowledge about how to change isn’t always enough Knowledge about how to change isn’t always enough People are creatures of habit People are creatures of habit Health consequences are often delayed Health consequences are often delayed Busy lifestyles require us to make time for self care Busy lifestyles require us to make time for self care

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Motivational Interviewing: Based on Theory Conceptualized according to stage model of change (Prochaska & DiClemente, 1982) Not everyone engages in treatment at the same stage of readiness Different type of approach may be utilized for individuals at different stages

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Traditional vs. Motivational The “Doctor”: Places the importance on the behavior change Places the importance on the behavior change Controls the interaction Controls the interaction May direct/select the goals the patient should achieve May direct/select the goals the patient should achieve The “patient”: Determines the importance of the behavior change Determines the importance of the behavior change Is listened to, shares concerns and needs Is listened to, shares concerns and needs Is supported in decisions about change and goals Is supported in decisions about change and goals 9

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Empathic Style of MI and Brief Interventions The key element in brief interventions is empathy The key element in brief interventions is empathy Research on empathy and clinical outcomes: Research on empathy and clinical outcomes: Strongest predictor of outcomes Not accounted for by demographics Not accounted for by treatment type

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11 Patient Focus MI supports the patient in articulating MI supports the patient in articulating How personally important this change (e.g., dietary) is, as opposed to how important we think it is How personally important this change (e.g., dietary) is, as opposed to how important we think it is What stands in the way of making this change (time, money, cultural factors, emotions, etc.) What stands in the way of making this change (time, money, cultural factors, emotions, etc.) Changes that might work in their life Changes that might work in their life How to increase the chances of success How to increase the chances of success

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Learning MI Techniques Listening Skills Spirit

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13 Spirit of Motivational Interviewing Evocative (vs. Educational) – patient is responsible for change. (“What would you gain if you changed your drinking?”) vs. implanting the right idea (“You really need to stop drinking.”) Evocative (vs. Educational) – patient is responsible for change. (“What would you gain if you changed your drinking?”) vs. implanting the right idea (“You really need to stop drinking.”) Honoring Autonomy (vs. Authority) – Allow the freedom not to change. (“How ready are you to change?) vs. push for commitment (“If you delay getting sober, you could die.”) Honoring Autonomy (vs. Authority) – Allow the freedom not to change. (“How ready are you to change?) vs. push for commitment (“If you delay getting sober, you could die.”) Collaborative (vs. Confrontational) – Work in Partnership. (“How about we discuss some options together” vs. “I would urge you to quit drinking.”) Collaborative (vs. Confrontational) – Work in Partnership. (“How about we discuss some options together” vs. “I would urge you to quit drinking.”)

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The Spirit of MI Motivation for change is elicited from within the patient, not imposed from outside Motivation for change is elicited from within the patient, not imposed from outside The patient must articulate reasons for change The patient must articulate reasons for change The patient is the one responsible to decide The patient is the one responsible to decide Direct persuasion is ineffective Direct persuasion is ineffective The clinician should steer the conversation to focus on change The clinician should steer the conversation to focus on change

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Ambivalence Interesting, natural, human, understandable Interesting, natural, human, understandable Not unique to characterological problems Not unique to characterological problems Not indicative of defense (denial) Not indicative of defense (denial) “I want to but I don’t want to” “I want to but I don’t want to” Unhelpful to think of people as “unmotivated” Unhelpful to think of people as “unmotivated”

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SPIRIT OF MI Ambivalence APPRECIATE AMBIVALENCE APPRECIATE AMBIVALENCE HONOR, EMBRACE, EXPLORE AMBIVALENCE. It’s the core. HONOR, EMBRACE, EXPLORE AMBIVALENCE. It’s the core. Many brief (and single session) therapies work by focusing on this ambivalence, not on skills (people frequently have the skills) Many brief (and single session) therapies work by focusing on this ambivalence, not on skills (people frequently have the skills)

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The RIGHTING Reflex “This person SHOULD want to change.” “This person SHOULD want to change.” NOW is the right time to change. NOW is the right time to change. A TOUGH/clear/honest approach is best. A TOUGH/clear/honest approach is best. Patient should follow my EXPERT ADVICE. Patient should follow my EXPERT ADVICE. If patient doesn’t change, the session FAILED. If patient doesn’t change, the session FAILED. There’s nothing we can do for the “unmotivated.” There’s nothing we can do for the “unmotivated.”

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Evaluate the Pros and Cons Reducing/Giving up Tobacco Pros (Good Things) Cons (Downsides) Smoking the Same I can still smoke with I friends It helps me deal with my stress It’s hard to breathe It’s a fire hazard It’s bad for my health It’s expensive Making Changes in Smoking Feel better Have more energy Have more money I wouldn’t be able to hang out with my friends who smoke I wouldn’t have a way to deal with my problems

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Evaluate the Pros and Cons Increasing Medication Adherence Pros (Good Things) Cons (Downsides) Stay the Same, i.e., Non-Adherent I can still smoke with I friends It helps me deal with my stress It’s hard to breathe It’s a fire hazard It’s bad for my health It’s expensive Making Changes, i.e., Adherent Feel better Have more energy Have more money I wouldn’t be able to hang out with my friends who smoke I wouldn’t have a way to deal with my problems

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(2) Develop Discrepancy Change is motivated by perceived discrepancy between present behavior and personal goals/values Discrepancy = importance of change for patient Amplify the discrepancy to move patient from the status quo Elicit discrepancy from the patient – they should make the argument for change

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(3) Roll with Resistance Argument often pushes person in the opposite direction Resistance is a call for the clinician to change, not the patient Questions and problems should be reflected back to the patient, not “solved” by the clinician

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(4) Support Self-Efficacy Be aware of your own beliefs about a patient’s ability to change (self-fulfilling prophecy) Enhance patient’s self-belief about his or her capability to make a change Be genuine

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31 Open Questions to Promote Change Disadvantages of the Status Quo How do you feel about your weight? How do you feel about your weight? Advantages of Change What would the benefits be for you, if you were to quit smoking ? What would the benefits be for you, if you were to quit smoking ? Optimism for Change What makes you feel that now is a good time to try something different? What makes you feel that now is a good time to try something different? Intention to Change What would you like to see happen? What would you like to see happen? How might things be different for you, if you did make a change? How might things be different for you, if you did make a change?

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Reflective Listening – The Foundation of MI “MINI-SUMMARIES” used strategically to lower resistance “MINI-SUMMARIES” used strategically to lower resistance Used to highlight patient statements favoring change (“Change Talk”) Used to highlight patient statements favoring change (“Change Talk”) A way of thinking, Difficult to learn A way of thinking, Difficult to learn Powerful for increasing readiness Powerful for increasing readiness Expert ratio 2 reflections for every question vs. Novice ratio.5 reflections for every question Expert ratio 2 reflections for every question vs. Novice ratio.5 reflections for every question

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Handy Reflections Double-Sided (reflects both sides of ambivalence) – takes the clinician out of the equation – puts the ambivalence in their own lap Double-Sided (reflects both sides of ambivalence) – takes the clinician out of the equation – puts the ambivalence in their own lap So on the one hand, you like how alcohol makes you feel and at the same time, you worry about your Hepatitis. So on the one hand, you like how alcohol makes you feel and at the same time, you worry about your Hepatitis. Amplified – can go in either direction Amplified – can go in either direction Undershoots so patient might elaborate, “You’re a LITTLE confused…” Undershoots so patient might elaborate, “You’re a LITTLE confused…” Overshoots so patient can back down, “So you don’t EVER intend to cut down…” Overshoots so patient can back down, “So you don’t EVER intend to cut down…”

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Handy Reflections Shifting Focus – shift patient’s concern away from a potential stumbling block – around barriers rather than over them Shifting Focus – shift patient’s concern away from a potential stumbling block – around barriers rather than over them c: “Okay, maybe I’ve got some problems with drinking, but I’m not alcoholic.” c: “Okay, maybe I’ve got some problems with drinking, but I’m not alcoholic.” Argument with a Twist – offer initial agreement, but with a slight twist or change of direction Argument with a Twist – offer initial agreement, but with a slight twist or change of direction

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36 Summarizing Helps the other person: Recall and reflect upon the conversation Recall and reflect upon the conversation Think of new ideas Think of new ideas Understand the importance of these issues Understand the importance of these issues Plan next steps Plan next steps Feel more confident, instill hope Feel more confident, instill hope

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37 Importance and Confidence Importance: lets you know how important this issue(s) is to the patient, in the grand scheme of other important values in their life Importance: lets you know how important this issue(s) is to the patient, in the grand scheme of other important values in their life Confidence: lets you know how able the patient feels he/she is to make specific changes towards his/her goal(s) Confidence: lets you know how able the patient feels he/she is to make specific changes towards his/her goal(s)

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38 Readiness Indicators Assessing Importance and Confidence Importance How important is it to you to ____________? On a scale of 0 to 10, with 0 being not important at all & 10 being very important… Not a all Somewhat Very Confidence How confident are you that you could _____________, if you decided to? On a scale of 0 to 10, with 0 being not confident at all & 10 being very confident? Not at all Somewhat Very

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39 Evaluating Importance/Confidence “What made you answer with a (number patient gave) and not a zero?” “What made you answer with a (number patient gave) and not a zero?” “What would it take for you to move from a (number patient gave) to a (slightly higher number)?” “What would it take for you to move from a (number patient gave) to a (slightly higher number)?”